Dog Complaint

1. CONTACT DETAILS

2. Your Name*

   Please give your full name.

3. Residential Address*
4. Postal Address
5. Telephone*
6. Email

7. COMPLAINT DETAILS

8. Nature of Your Complaint* Dog/s Barking Dog/s Wandering Dog/s Attack - provide additional details below Other Complaint - provide additional details below

   Select the relevant option.

9. Breed / Description of Dog/s*

   If not known, enter "Unknown".

10. Dog Owner Details*

    If no details available, enter "Details Not Known".

11. Date of Offence*
12. Time of Offence*

    Provide time in 24 hour format, or include am/pm. If time of offence not known, enter "Time Not Known".

13. Location of Offence*

14. Dog Attack

    If "Dog/s Attack" selected at "Nature of Your Complaint" provide additional information below.

15. Physical Injury YesNo

    Was physical injury caused?

16. Medical Treatment YesNo

    Was doctor / hospital treatment received? If Yes, provide additional information below.

17. Medical Treatment - Additional Information

    If medical treatment received, please provide name of doctor/hospital, date and time of treatment.

18. Extent & Location of Injuries

    Provide details of injuries sustained in the attack.

19. Other Damage

    Provide details of other damage received, ie to clothing, bicycle, property, etc.

20. Other Complaint

    If "Other Complaint" selected at "Nature of Your Complaint", provide details of your complaint below.

21. Other Complaint Details

22. Additional Information

    Provide below any other information you think may be relevant.

23. Additional Information
24. DATE SUBMITTED*

    Provide the date you are submitting this form

* denotes a required field.